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Women’s Issues and Epilepsy

Women’s Issues and Epilepsy. Deana M. Gazzola, M.D. Instructor, NYU School of Medicine NYU Comprehensive Epilepsy Center NYU Women’s Epilepsy Center, Co-Director. Lara V. Marcuse, M.D. Instructor, NYU School of Medicine NYU Comprehensive Epilepsy Center. Topics. Dr. Gazzola:

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Women’s Issues and Epilepsy

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  1. Women’s Issues and Epilepsy Deana M. Gazzola, M.D. Instructor, NYU School of Medicine NYU Comprehensive Epilepsy Center NYU Women’s Epilepsy Center, Co-Director Lara V. Marcuse, M.D. Instructor, NYU School of Medicine NYU Comprehensive Epilepsy Center

  2. Topics Dr. Gazzola: • General Overview – Hormones • Catamenial Epilepsy and treatment • Bone Health Dr. Marcuse: • AED Pregnancy Registries • Breastfeeding • Birth Control

  3. What makes Women with Epilepsy Unique? Why do we give this talk? • Hormones affect seizures. • Pregnancy can affect seizures and antiepileptic drugs. • Antiepileptic drugs can affect baby. • Antiepileptic drugs can affect bone health, and women are at increased risk of osteoporosis.

  4. Hormones and the Menstrual Cycle

  5. The Hormonal Effect • Estrogen = Pro-convulsant • Progesterone = Anti-convulsant • Estrogen levels gradually increase approximately 2-4 years prior to the first menses. • Progesterone production increases after the first ovulation (about 1-2 years after menarche).

  6. The Hormonal Effect • There is a relative “pro-convulsant” state for several years, during which estrogen effects outweigh progesterone effects. • During this period, young women may experience an increase in seizure frequency. • Several studies have shown worsened seizures during puberty or menarche in approximately one-third of young women.

  7. The Hormonal Effect: Catamenial Epilepsy • Catamenial derived from “katamenios” (monthly). • Seizures increase or occur exclusively during a certain phase of the menstrual cycle.

  8. Catamenial Epilepsy: History • Galen: “(the moon’s) effects were weak at half moon, but strong at full moon.” • Middle Ages: Vapor arising from the uterus thought to induce attacks. • Sir Charles Locock first described the relationship between seizures and the menstrual cycle in 1857.

  9. Catamenial Epilepsy: History • Gowers described the first series of menses-related seizures affecting 46 of 82 women in 1881.

  10. Catamenial epilepsy: Categories • Periovulatory (about 2 weeks before ovulation) *high estrogen:progesterone ratio) • Perimenstrual (within the week before and during menses) *high estrogen:progesterone ratio)

  11. Hormone Levels Day of Cycle Perimenstrual Periovulatory Estrogen level Progesterone Level Luteal phase (Ovulation) Menses Also refer to image at: http://www.epilepsyfoundation.org/answerplace/Life/adults/women/Professional/hormone.cfm

  12. Catamenial Epilepsy: Treatment • Acetazolamide • Unclear how it works. • Little data documenting efficacy. • One study (referenced in Foldvary et al, Cleveland Clinic Study) of 20 women showed that seizure frequency was significantly reduced in 40% patients, and seizure severity in 30% of patients.

  13. Catamenial Epilepsy: Treatment • Problems with acetazolamide: • Side effects • Tolerance

  14. Catamenial Epilepsy: Treatment • Cyclic Antiepileptic Drug Use: • Feely et al. studied in clobazam use (benzodiazepine) • Administered to 24 women for 10 days beginning 2-4 days before menses. • Sustained effects were seen in 13 women over 6-13 months. • 10 were seizure-free perimenstrually. • Side effects of depression, lethargy • The cyclic increase in dosage of other antiepileptic drugs has not yet been adequately studied.

  15. Catamenial Epilepsy: Treatment • Hormonal Therapy: • Isolated anecdotal cases of improved seizure control in women treated with birth control have been described. • Sparse literature • Natural progesterone in the form of lozenges has been shown to be helpful in some cases (Herzog et al) • Of 15 women followed for 3 years, 20% became seizure-free • There was an overall seizure reduction of 62% for partial seizures and 74% for convulsions in these 15 patients.

  16. We Need Your Help! • We need more, and better-designed, trials to find answers to these questions.

  17. Bone Health • Certain antiepileptic drugs (AEDs) affect bone mineral density. • Increased risk of fracture in patients on AEDs. • Certain AEDs decrease vitamin D and calcium levels.

  18. AEDs that can affect bone health: • Carbamazepine (Tegretol) • Oxcarbazepine (Trileptal) • Phenobarbital (Luminal) • Phenytoin (Dilantin) • Valproic acid (Depakote) • No studies/unclear results in Topiramate, Zonisamide, Levetiracetam and Lamotrigine.

  19. Bone Health: Screening • We currently have no standard recommendations for screening. • Protocol: • Obtain baseline DEXA scan. • If normal, screen every 3 years unless at high risk. • If abnormal, closer monitoring (yearly).

  20. Vitamin D and Calcium Supplementation • Vitamin D is needed for calcium to be absorbed from the intestines. • Vitamin D also plays an important role in bone formation. • Therefore it is important to take BOTH calcium and Vitamin D supplementation.

  21. Remember to take care of your bones!

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